He came to the New Mexico Heart Institute because a friend had died suddenly of a heart attack. MB had several risk factors for heart disease, including a sedentary lifestyle, obesity, high cholesterol and hypertension. He also was highly stressed and angry. (To read the earlier column, go to abqjournallivewell.com/2012/09/01/catching-heart-disease-early-is-crucial/.)
MB’s risk for heart attack, stroke or death was between 10 percent and 20 percent over the next 10 years. His risk was further increased when we discovered he had significant calcium plaque in his coronary arteries based on a coronary CT scan.
He has many problems to address.
In this column, we will address the approach to controlling his blood pressure. MB wanted to try to lower his blood pressure “naturally,” meaning without medication. I suggested three avenues: weight loss, diet and medication.
I advised him to start measuring his blood pressure at home. Home blood pressures are far more reliable than the hurry-up-rush blood pressure you get in the doctor’s office. I know that when I go to the doctor I do everything I can to relax so that my blood pressure will go down. I asked him to record his blood pressure twice a day for a month, when we would review the results. I assured him that the automatic blood pressure monitors were accurate and easy-to-use. If you have high blood pressure, buy one. It’s the best $60 you’ll ever spend.
The diet with the most research showing it lowers blood pressure is the DASH diet (dashdiet.org). It is a plant-based diet but you can still have meat and it is somewhat salt-restricted. It will help with weight loss and also make your cholesterol numbers better. It contains less than 2,300 mg of salt a day. That’s about 1 teaspoon.
MB eats out a lot and I advised him that he can cut down on his salt by asking that food be cooked without salt and by paying attention to items in the menu that are known to be loaded with salt.
MB needed to learn how to read food labels. He discovered how much salt there is in things that we don’t think of as being salty – for example bread, rice, pasta and potatoes, as well as processed meats. He needed to start eating fresh foods and enhancing the taste with spices, citrus-flavored vinegar and salt substitutes. Anyone going on this diet should do it slowly, but I believe you can retrain your taste buds so that after a couple of weeks food with a lot of salt in it won’t taste good. (See some label definitions in box at bottom.)
Like many of our patients at the Heart Institute, MB couldn’t faithfully follow the diet I had laid out for him. He needed medication because his blood pressure was still out of range at 150/90. His goal was 140. Convincing him was a problem, as he had experienced some side effects from drugs previously. I explained that high blood pressure is a silent disease and the first symptom could be a stroke. Despite reservatons about medications, most people will choose medication over the high risk for stroke.
We have four major classes of medications to treat high blood pressure. Until recently, the guidelines cardiologists used indicated that, except for beta-blockers, the other three classes were essentially equal.
Beta-blockers have been the mainstay of anti-hypertensive therapy. We now know that although these drugs can lower blood pressure there is scant evidence that they prevent heart attacks or strokes when used alone to control blood pressure. The drugs also raise blood sugar and cause weight gain. Atenolol, the world’s most prescribed drug for hypertension, is no longer considered a first-line drug. Newer beta blockers like carvedilol do not have the same effects.
Diuretics or water pills are still the mainstay of anti-hypertensive therapy. This class of drug is often used alone. Our guidelines recommend a longer acting diuretic like chlorthalidone rather than the popularly prescribed hydrochlorothiazide. That means a lot of people need to change their diuretic. Chlorthalidone has a much longer half-life than hydrochlorothiazide and provides a smoother control of blood pressure. This class of drugs can cause loss of potassium concentration and needs to be monitored.
Calcium channel blockers are a second group of effective drugs to control blood pressure. They are well-tolerated but sometimes cause swelling of the lower extremities. Drugs in this group are amlodipine, diltiazem and verapamil. Unlike the diuretics, which have an effect on blood volume, these drugs work because they dilate the blood vessels and reduce blood pressure.
The third class of anti-hypertension agents is ACE inhibitors and A2 blockers. These drugs are complicated but work by dilating blood vessels. They are effective alone and also protect the kidneys in patients with kidney disorders.
The goal of only using a single drug is changing after a huge clinical trial called ACCOMPLISH. In it researchers studied more than 11,000 patients with hypertension and found the combination of the calcium channel blocker amlodipine and an ACE inhibitor produced the greatest reduction in the number of heart attacks, strokes or deaths compared to any of the other agents by themselves.
Often patients will require more than two drugs to control the blood pressure to below 140/90. MB did, and although he was initially discouraged, he now has good blood pressures and because he feels better, he is exercising. In the future, we will discuss his exercise program and his attempt to lose weight. All of these goals will reduce his blood pressure and make him live longer.
Dr. Barry Ramo is a cardiologist with the New Mexico Heart Institute and medical editor for KOAT-TV. Send questions for him to Albuquerque Journal Live Well, P.O. Drawer J, Albuquerque, NM 87103, or email them to firstname.lastname@example.org.
Read the label
These terms are used to describe the sodium content on food labels.
SODIUM FREE: A tiny amount of sodium in each serving
VERY LOW SODIUM: 35 milligrams or less in each serving
LOW SODIUM: 140 milligrams or less in each serving
REDUCED SODIUM: Usual level of sodium is reduced by 25 percent
LIGHT OR LITE IN SODIUM: Usual level of sodium is reduced by 50 percent